An economic analysis of payment for health care services: The United States and Switzerland compared

This article seeks to assess whether physician payment reforms in the United States and Switzerland were likely to attain their objectives. We first introduce basic contract theory, with the organizing principle being the degree of information asymmetry between the patient and the health care provider. Depending on the degree of information asymmetry, different forms of payment induce "appropriate” behavior. These theoretical results are then pitted against the RBRVS of the United States to find that a number of its aspects are not optimal. We then turn to Switzerland's Tarmed and find that it fails to conform with the prescriptions of economic contract theory as well. The article closes with a review of possible reforms that could do away with uniform fee schedules to improve the performance of the health care syste

Advancing Learning Health Systems Through Embedded Research: The 23rd Annual Conference of the Health Care Systems Research Network

The 23rd annual conference of the Health Care Systems Research Network (HCSRN, formerly the HMO Research Network) was held in San Diego, California, March 21–23, 2017, attracting 387 attendees. As a consortium of 20 research organizations embedded in or affiliated with large health care delivery organizations, the HCSRN has held annual research conferences since 1994. The overall aim of the conferences is to bring researchers, project staff, research funders and other stakeholders together to share latest scientific findings and foster new research ideas and collaborations. The 2017 conference was hosted by the Palo Alto Medical Foundation Research Institute. Each host site takes responsibility for the content and structure of the conference, and the 2017 team introduced several new features. In particular, past conferences used concurrent sessions to present research results in different topical areas, such as chronic disease, cancer, health informatics, mental health or precision medicine. This year, concurrent sessions shifted to panel discussions about how research results were achieved, including the use of methods, partnerships and analytic approaches. The 35 panels were organized into tracks such as engagement, data and informatics, partnerships and research implementation. Scientific results from HCSRN projects were presented via 120 posters in two poster sessions. Plenary sessions included a town hall-style panel with different funding agency representatives, an opening presentation on the range of opportunities and benefits to studying health systems, and a concluding presentation on how researchers can apply design thinking in their work

Patient and Physician Race and the Allocation of Time and Patient Engagement Efforts to Mental Health Discussions in Primary Care: An Observational Study of Audiorecorded Periodic Health Examinations

This study investigated racial differences in patient-physician communication around mental health versus biomedical issues. Data were collected from audiorecorded periodic health examinations of adults with mental health needs in the Detroit area (2007-2009). Patients and their primary care physicians conversed for twice as long, and physicians demonstrated greater empathy during mental health topics than during biomedical topics. This increase varied by patient and physician race. Patient race predicted physician empathy, but physician race predicted talk time. Interventions to improve mental health communication could be matched to specific populations based on the separate contributions of patient and physician race

Periodic Health Examinations and Missed Opportunities among Patients Likely Needing Mental Health Care

Periodic health examinations (PHEs) are the most common reason adults see primary care providers. It is unknown if PHEs serve as a "safe portal" for patients with mental health needs to initiate care. We examined how physician communication styles impact mental health service delivery in PHEs

Automated rating of patient and physician emotion in primary care visits

OBJECTIVE: Train machine learning models that automatically predict emotional valence of patient and physician in primary care visits. METHODS: Using transcripts from 353 primary care office visits with 350 patients and 84 physicians (Cook, 2002 [1], Tai-Seale et al., 2015 [2]), we developed two machine learning models (a recurrent neural network with a hierarchical structure and a logistic regression classifier) to recognize the emotional valence (positive, negative, neutral) (Posner et al., 2005 [3]) of each utterance. We examined the agreement of human-generated ratings of emotional valence with machine learning model ratings of emotion. RESULTS: The agreement of emotion ratings from the recurrent neural network model with human ratings was comparable to that of human-human inter-rater agreement. The weighted-average of the correlation coefficients for the recurrent neural network model with human raters was 0.60, and the human rater agreement was also 0.60. CONCLUSIONS: The recurrent neural network model predicted the emotional valence of patients and physicians in primary care visits with similar reliability as human raters. PRACTICE IMPLICATIONS: As the first machine learning-based evaluation of emotion recognition in primary care visit conversations, our work provides valuable baselines for future applications that might help monitor patient emotional signals, supporting physicians in empathic communication, or examining the role of emotion in patient-centered care

Implementation of Patient Engagement Tools in Electronic Health Records to Enhance Patient-Centered Communication: Protocol for Feasibility Evaluation and Preliminary Results

BACKGROUND: Patient-physician communication during clinical encounters is essential to ensure quality of care. Many studies have attempted to improve patient-physician communication. Incorporating patient priorities into agenda setting and medical decision-making are fundamental to patient-centered communication. Efficient and scalable approaches are needed to empower patients to speak up and prepare physicians to respond. Leveraging electronic health records (EHRs) in engaging patients and health care teams has the potential to enhance the integration of patient priorities in clinical encounters. A systematic approach to eliciting and documenting patient priorities before encounters could facilitate effective communication in such encounters. OBJECTIVE: In this paper, we report the design and implementation of a set of EHR tools built into clinical workflows for facilitating patient-physician joint agenda setting and the documentation of patient concerns in the EHRs for ambulatory encounters. METHODS: We engaged health information technology leaders and users in three health care systems for developing and implementing a set of EHR tools. The goal of these tools is to standardize the elicitation of patient priorities by using a previsit patient important issue questionnaire distributed through the patient portal to the EHR. We built additional EHR documentation tools to facilitate patient-staff communication when the staff records the vital signs and the reason for the visit in the EHR while in the examination room, with a simple transmission method for physicians to incorporate patient concerns in EHR notes. RESULTS: The study is ongoing. The anticipated completion date for survey data collection is November 2021. A total of 34,037 primary care patients from three health systems (n=26,441; n=5136; and n=2460 separately recruited from each system) used the previsit patient important issue questionnaire in 2020. The adoption of the digital previsit questionnaire during the COVID-19 pandemic was much higher in one health care system because it expanded the use of the questionnaire from physicians participating in trials to all primary care providers midway through the year. It also required the use of this previsit questionnaire for eCheck-ins, which are required for telehealth encounters. Physicians and staff suggested anecdotally that this questionnaire helped patient-clinician communication, particularly during the COVID-19 pandemic. CONCLUSIONS: EHR tools have the potential to facilitate the integration of patient priorities into agenda setting and documentation in real-world primary care practices. Early results suggest the feasibility and acceptability of such digital tools in three health systems. EHR tools can support patient engagement and clinicians\u27 work during in-person and telehealth visits. They could potentially exert a sustained influence on patient and clinician communication behaviors in contrast to prior ad hoc educational efforts targeting patients or clinicians. TRIAL REGISTRATION: ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/ct2/show/NCT03385512. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30431

Decision or No Decision: How Do Patient–Physician Interactions End and What Matters?

BACKGROUND: A clearly stated clinical decision can induce a cognitive closure in patients and is an important investment in the end of patient–physician communications. Little is known about how often explicit decisions are made in primary care visits. OBJECTIVE: To use an innovative videotape analysis approach to assess physicians’ propensity to state decisions explicitly, and to examine the factors influencing decision patterns. DESIGN: We coded topics discussed in 395 videotapes of primary care visits, noting the number of instances and the length of discussions on each topic, and how discussions ended. A regression analysis tested the relationship between explicit decisions and visit factors such as the nature of topics under discussion, instances of discussion, the amount of time the patient spoke, and competing demands from other topics. RESULTS: About 77% of topics ended with explicit decisions. Patients spoke for an average of 58 seconds total per topic. Patients spoke more during topics that ended with an explicit decision, (67 seconds), compared with 36 seconds otherwise. The number of instances of a topic was associated with higher odds of having an explicit decision (OR = 1.73, p < 0.01). Increases in the number of topics discussed in visits (OR = 0.95, p < .05), and topics on lifestyle and habits (OR = 0.60, p < .01) were associated with lower odds of explicit decisions. CONCLUSIONS: Although discussions often ended with explicit decisions, there were variations related to the content and dynamics of interactions. We recommend strengthening patients’ voice and developing clinical tools, e.g., an “exit prescription,” to improving decision making

A Randomized Controlled Effectiveness Trial for PSA Screening Decision Support Interventions in Two Primary Care Settings

BACKGROUND Decision support interventions (DESIs) provide a mechanism to translate comparative effectiveness research results into clinical care so that patients are able to make informed decisions. Patient decision support interventions for prostate-specific antigen (PSA) have been shown to promote informed decision making and reduce PSA testing in efficacy trials, but their impact in real world settings is not clear. OBJECTIVE We performed an effectiveness trial of PSA decision support interventions in primary care. DESIGN A randomized controlled trial of three distribution strategies was compared to a control. PARTICIPANTS Participants included 2,550 men eligible for PSA testing (76.6 % of the eligible population) and 2001 survey respondents (60.1 % survey response rate). INTERVENTIONS The intervention groups were: 1) mailed the DESI in DVD format, 2) offered a shared medical appointment (SMA) to view the DESI with other men and discuss, and 3) both options. MAIN MEASURES We measured PSA testing identified via electronic medical record at 12 months and DESI use by self-report 4 months after the intervention mailing. KEY RESULTS We found no differences in PSA testing across the three distribution strategies over a year-long follow-up period: 21 %, 24 %, 22 % in the DESI, SMA, and combined group respectively, compared to 21 % in the control group (p = 0.51). Self-reported DESI use was low across all strategies at 4 months: 16 % in the mailed DESI group, 6 % in the SMA group, and 15 % in the combined group (p = < 0.0001). CONCLUSIONS Mailing PSA decision support interventions or inviting men to shared medical appointments unrelated to a primary care office visit do not appear to promote informed decision making, or change PSA testing behavior

Using CollaboRATE, a brief patient‐reported measure of shared decision making: Results from three clinical settings in the United States

Abstract Introduction: CollaboRATE is a brief patient survey focused on shared decision making. This paper aims to (i) provide insight on facilitators and challenges to implementing a real‐time patient survey and (ii) evaluate CollaboRATE scores and response rates across multiple clinical settings with varied patient populations. Method All adult patients at three United States primary care practices were eligible to complete CollaboRATE post‐visit. To inform key learnings, we aggregated all mentions of unanticipated decisions, problems and administration errors from field notes and email communications. Mixed‐effects logistic regression evaluated the impact of site, clinician, patient age and patient gender on the CollaboRATE score. Results: While CollaboRATE score increased only slightly with increasing patient age (OR 1.018, 95% CI 1.014‐1.021), female patient gender was associated with significantly higher CollaboRATE scores (OR 1.224, 95% CI 1.073‐1.397). Clinician also predicts CollaboRATE score (random effect variance 0.146). Site‐specific factors such as clinical workflow and checkout procedures play a key role in successful in‐clinic implementation and are significantly related to CollaboRATE scores, with Site 3 scoring significantly higher than Site 1 (OR 1.759, 95% CI 1.216 to 2.545) or Site 2 (z=−2.71, 95% CI −1.114 to −0.178). Discussion This study demonstrates that CollaboRATE can be used in diverse primary care settings. A clinic's workflow plays a crucial role in implementation. Patient experience measurement risks becoming a burden to both patients and administrators. Episodic use of short measurement tools could reduce this burden